We're On to Go

A long drive to Seattle, but a sunny day to do it in.  We got there just in time (4 p.m.) for the 4-phase CT liver scan, only to find that the order was for a chest/abdomen/liver scan, which is the scan Ed had just 6 weeks ago.  So, Ed says, 'Wrong orders; get hold of Dr. Park," (Dr. Park is the surgeon; Dr. Park is the patient).  The radiologists and techs scurried around and Ed emailed Dr. Park the surgeon and after awhile, everybody came back with a new order that included, now, both the 4-phase liver and the 3-parts scans.  All of which then took about 10 minutes and we were free until the next morning.

The Med Center had arranged for us to have a room cross campus and we got to walk about there a little bit.  Neither of us had ever been there and it was surprisingly large for those of us who are used to UCLA.  Not only bigger but many more old buildings, or at least older appearing buildings, than UCLA.  We took a bus downtown to the Public Market.  Ate   dinner at a Thai restaurant.  Walked around a bit more.  Took the bus back to the University District.  Read for awhile and spent a restless night because it seemed like the noisiest place I had ever been.  Planes going over constantly; sirens with great frequency, very loud trucks going close by all night.  People walking and talking.  At 6 a.m., a large green truck drove up into the alleyway just outside our three windows and proceeded to spend about 30 minutes eating a sizable building.  (Later, I was told it was a garbage truck making the weekly pickup for the hotel, but I have truly never heard anything like it: great sounds of crunching of metal and wood.)

So we made our way back to the Med Center for the 8:30 a.m. meeting with the Senior Surgery Resident, a cheerful and talkative guy from Los Angeles.  He went through his spiel for our benefit and also for the benefit of a 9-year-old undergraduate who was thinking of going to medical school and was spending some time seeing what he did.  She was about the most timid person I have seen in a long time.  Even when everybody was trying to include her, she was trying to disappear.  I think pathology might be the right place for her if she pursues this line of work.  After doing a brief history of Ed and his medical adventures for the past year, the Resident went off to a conference where Ed and one other patient were being presented as candidates for liver surgery.  The conference included the frightened student, the residents, the liver surgeon (one of two: the other was out of town), the medical oncologists, the interventional radiologists, and a nurse and an ethicist. (No, I'm just joking about the latter two).

We were sent off to entertain ourselves in the Med Center (not the hospital) which has a wonderful art collection and entertained we were.  Plus a little breakfast.

At 11 a.m., we're back to meet the surgeon Dr. Park, the Resident (Dr. Lao), and the student (Frances) for the discussion.  There was nothing really new here.  Park had previously said he saw no reason that Ed would not, from a technical perspective, be eligible for the surgery.  And, given that he had previously seen the history, he knew that Ed was not in the most desirable candidates list.  U.W.'s risk assessment includes 5 characteristics, all of which Ed does poorly in (anatomical, mostly: size of primary liver tumor, CEA levels at initial discovery, etc.)  So humiliating for people who usually test well to find that they are getting minus grades on the standards.  So, he ends up with a -5, but he has great performance status (how well he is with respect to daily activities) and excellent response to chemo in his favor.  Surgeon Park thinks the surgery is a reasonable option but the advertised outcomes (58% surviving 5 years) really don't apply to the higher risk group Ed is in.  It's considerably less for the 'minus fives' who survive 5 years (and there were only 14 of them in the study).  Mortality from the surgery (counted as 90 days out from surgery) is low; morbidity/complication is high (42% overall): hemorrhage, transfusion, liver failure, bile duct leakage, etc.  (Ed has been reading the research that this risk scale is derived from and has some questions about how best to interpret it in order to judge whether he's -5 or -3, depending upon technical factors: he has written the Sloan Kettering author for clarification.)

What I did appreciate again was the way in which the docs conceptualize this situation.  They don't for a minute think its curable; there are cancer cells here and there throughout the body.  The surgeon can cut out only what he can see.  And what he can't see will be back eventually, calling for another round of treatment. if the patient can bear up under it.  The medical oncologist can kill what he can't see, but he can't kill it all because the cancer cells that survive the chemo are the stronger, resistant ones, so over time, they just get stronger, more resistant to chemo.

We thanked everyone, and they were worthy of thanks.  They were informative cheerful, helpful, and pleasant.  They were not rushing us through the discussion.  Indeed, I had hardly expected such talkative surgeons.  We drove back home into the rain.

And the bottom line is that Ed is now scheduled for surgery on June 23.  The surgery is usually done laparascopically.  Best case scenario for Ed is about 40% of the liver removed, but it could be more; you can survive with only a quarter of it if it's the right quarter.  The surgery takes 4-5 hours; ICU overnight, 2 days close monitoring for bleeding, total hospital stay of 5-7 days.  The bottom, bottom line is effectively that, if this works okay, Ed will have a chance for more time that will be better because the liver tumors currently there will not be dragging down his physical condition, and the price of this is a difficult surgery.  It's a gamble because enduring the surgery, and especially with complications, is worth it only if you get the extra time which you might or might not. And there's no way to know whether you will.  The cancer will recur.    And he has to have another colonoscopy to make sure that the cancer has not already recurred in the remaining colon.  That was almost a deal breaker for him.  Colonoscopies: that bad.